Case Report Lung Ultrasound in Early Diagnosis of Neonatal...

Case ReportLung Ultrasound in Early Diagnosis ofNeonatal Ventilator Associated Pneumonia beforeAny Radiographic or Laboratory Changes

Mohammed Ibrahim,1 Ahmed Omran,1 Mostafa Ibrahim,2

Nouran Bioumy,1 and Sonya El-Sharkawy1

1Departments of Pediatrics & Neonatology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt2Department of Radiodiagnosis, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Correspondence should be addressed to Ahmed Omran; [email protected]

Received 7 July 2016; Accepted 18 October 2016

Academic Editor: John W. Berkenbosch

Copyright © 2016 Mohammed Ibrahim et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Neonatal pneumonia is reported to be the primary cause of neonatal respiratory failure and one of the common causes of neonatalhospitalization and death in developing countries. Chest X-ray was considered the gold standard for diagnosis of neonatal pneu-monia. Lung ultrasonography has been described as a valuable noninvasive tool for the diagnosis of many neonatal pulmonarydiseases. We report a case of ventilation associated neonatal pneumonia with very early diagnosis using lung ultrasound before anysignificant radiographic changes in chest X-ray or laboratory findings suggestive of infection.

1. Introduction

Neonatal pneumonia is a serious respiratory infectious dis-ease considered the most common infectious disease in neo-nates and is a significant cause of neonatal deaths.Worldwideneonatal pneumonia accounts for up to 10% of childhoodmortality, with the highest case fatality rates being reportedin the developing countries [1, 2].

In neonatal pneumonia timely and accurate diagnosis isimportant to start appropriate treatment early and improvethe patient outcome. In the past, diagnosis of neonatal pneu-monia was mainly depending on the clinical diagnosis andchest radiographic findings. Recently, lung ultrasound (LUS)emerged as a modality of diagnosis in multiple neonatalpulmonary disorders including respiratory distress syndrome(RDS) [3], meconium aspiration syndrome (MAS) [4], tran-sient tachypnea of the newborn (TTN) [5], and neonatalpneumonia [6].

Here, we present a case of ventilator associated neonatalpneumonia (VAP) with very early diagnosis using LUS beforeeither radiographic or laboratory changes.

2. Case Presentation

A one-day-old female newborn was admitted to the neonatalintensive care unit (NICU) of Suez Canal University, Ismailia,Egypt, after uneventful prolonged vaginal delivery endedwith urgent cesarean section (CS). At admission the neonatesuffered from depressed activity and grade IV respiratorydistress with the need for mechanical ventilation.

The prenatal history was insignificant apart from prema-ture rupture ofmembranes 12 hours before the delivery.Thereis no history of maternal urinary tract infection, asthma, ordiabetes mellitus. The trial of the vaginal delivery lasted for10 hours with failure to progress and fetal distress on therecording cardiotocography that urged CS delivery. TheAPGAR score at 1 minute was 2, at 5 minutes was 4, and at10min was 4.

By the end of the 2nd day the basic laboratory investi-gations were withdrawn showing no abnormal findings withC-reactive protein (CRP) value 2mg/dL. The chest X-ray(CXR) showed only increased bronchovascular markings(Figure 1(a)). On the next day theGlasgowComa Scale (GCS)

Hindawi Publishing CorporationCase Reports in PediatricsVolume 2016, Article ID 4168592, 4 pageshttp://dx.doi.org/10.1155/2016/4168592

2 Case Reports in Pediatrics

(a) (b)

(c) (d)

Figure 1:The serial radiographic changes with the development of VAP. A serial of plain chest radiographs along twelve days was obtained insupine anteroposterior position.The first five-day images (a and b) showed normal aeration with average lung volumes, normal mediastinum,and clear costophrenic angles. Also prominent bronchovascular markings are seen, but there is no focal pulmonary lesions. On 6-day image(c), an opacity is developed on the right lower lung zone with air-bronchogram and obliteration of the right costophrenic and cardiophrenicangles, suggesting consolidation. By the twelfth day (d), complete opacification of the right lung is seen causing opaque right hemithoraxwith mild tracheal deviation to the contralateral left side suggesting development of right pleural effusion. Also small consolidation patchesare seen in the left para-cardiac region in middle and lower left lung zones with obliteration of the left cardiac border.

of the patient started to improve with progressive loweringthe settings of the mechanical ventilator. LUS screening wasdone after the arterial blood gases (ABGs) showed impairedoxygenation and ventilation and the new CXR was free(Figure 1(b)). The LUS showed multiple large consolidationswith thickened irregular pleural line, absent A-lines, andcoalescent B-lines around the consolidations suggesting thepossibility of ventilator associated pneumonia (VAP) (Figures2(a), 2(b), and 2(c)). AnewCRPat this point alsowas negative(3mg/dL) with leucocytic count 5,600/cmm and negativecultures.

One day later the settings of the mechanical ventilatorbecame higher, and the follow-up CXR showed right lowerpneumonic consolidation associated with collapse. Lungauscultation did not reveal any fine or coarse crepitations butonly slightly diminished air entry over the right side.TheCRPstarted to rise a day later (56mg/dL)with increased leucocyticcount (18,600/cmm) with absolute neutrophilia. Three dayslater the blood culture was positive. The diagnosis of VAPwas made and the antibiotics were changed according to theculture and sensitivity results.

The 7th day witnessed deterioration of the general con-dition with markedly impaired aeration of the right lung. A

new plain CXR was done (Figure 1(c)) showing large opacitydeveloped on the right lower lung zonewith air-bronchogramand obliteration of the right costophrenic and cardiophrenicangles, suggesting consolidation collapse.

The following 3 days showed no improvement in eitherthe chest condition or the ventilator settings guided by theABGs. So the antibiotics were changed to Vancomycin, Imi-penem/Cilastatin, and Diflucan according to the local NICUprotocols of antibiotics’ usage.

By the 11th day, there was progressive deterioration withinadequate response to the medical and ventilatory support.A new plain CXR (Figure 1(d)) which showed completeopacification of the right lung is seen causing opaque righthemithorax. Also small consolidation patches are seen in theleft para-cardiac region in middle and lower left lung zoneswith obliteration of the left cardiac border.

The failure of ventilation and oxygenation on high ven-tilator settings showed the need to transfer the neonate to acenter with high frequency oscillatory ventilation (HFOV)or extracorporal membrane oxygenation (ECMO). How-ever, there was no available place for transfer at that time.Respiratory failure then developed with eventual cardiacarrest.

Case Reports in Pediatrics 3

(a)

Pleural lineirregularity

(b) (c)

Figure 2: The LUS findings associated with VAP. Superficial high resolution lung ultrasound was done and images obtained in midaxillary(a), scapular (b), and midclavicular (c) lines at transverse and longitudinal planes. Multiple peripheral hypoechoic areas are seen whichassume subpleural location showing irregular borders and air-bronchogram inside, suggesting pneumonic consolidations (solid arrows).Also thickened irregular pleural borders (empty arrow) with absent A-lines and coalescent B-lines around the consolidations (arrow heads).

3. Discussion

Respiratory disorders are the most frequent causes of admis-sion to the NICU in both term and preterm infants. World-wide pneumonia accounts for 15% of the total number ofdeaths in children less than 5 years [7]. Early diagnosis ofneonatal pneumonia still remains a diagnostic challenge [8].UsingX-ray as a “gold standard” for the diagnosis of pneumo-nia, however, it should be used cautiously in neonates becauseof the potential late adverse effects of ionized radiation [9, 10],and the lack of findings on chest radiographs does not rule outthe diagnosis if there is a strong suspicion of pneumonia.

Recently, there has been a great interest in developingnew tools to increase the accuracy of pneumonia diagnosiswith simultaneous decrease in exposure to ionized radiationespecially in neonates. Advances in ultrasound technologyhave made LUS a potential attractive option for the diagnosisof pneumonia. Moreover, ultrasound is safe, portable, inex-pensive, and relatively easy to teach.

A recent meta-analysis of studies comparing lung ultra-sound versus CXR and chest CT scan for the diagnosis ofpneumonia showed good sensitivity and specificity in chil-dren and adults [11, 12]. LUS was very close to CXR in iden-tifying pulmonary abnormalities among children with sus-pected pneumonia with a 97% specificity for CXR-confirmedpneumonia [13]. Similarly, LUS had an overall sensitivity of86% and specificity of 89% for diagnosing pneumonia whencompared with CXR as reference standard [14].

Current evidence supports LUS as an imaging alternativefor the diagnosis of neonatal respiratory disorders. Liu et al.’sstudy demonstrates that LUS is useful for the diagnosis ofsever neonatal pneumonia [6]. LUS is also a reliable methodto diagnose RDS and TTN in newborns with respiratorydistress, with high sensitivity and specificity comparable withCXR [3]. LUS is a useful and promising tool in the diagnosisand management of MAS [4]. LUS is an accurate and reliable

method for diagnosing neonatal pulmonary atelectasis (NPA)[15]. LUS is found to be superior to CXR in the detection ofcomplications of RDS, particularly consolidation, atelectasis,and microabscesses [16].

The LUS in our case showed very early signs of pneu-monia includingmultiple large consolidationswith thickenedpleural line and absent A-lines. Liu et al. reported that largeareas of lung consolidation with irregular margins had 100%sensitivity and 100% specificity for the diagnosis of neonatalpneumonia; they also reported pleural line abnormalities in90% of their cases [6].

In our reported case LUS detected signs of pneumoniabefore any change in CXR and also before any change in thelaboratory markers. In cases of neonatal pulmonary atelecta-sis, LUS was more sensitive in detecting occult lesions thanCXR [15].

In this case report we present an early and accuratediagnosis of VAP using LUS in Egyptian neonate before anyradiographic or laboratory changes. This case may add a newdimension in using LUS as noninvasive method of diagnosisin neonatal VAP.

Competing Interests

The authors declare that they have no competing interests.

Authors’ Contributions

Mohammed Ibrahim and Ahmed Omran equally shared inthis work.

References

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4 Case Reports in Pediatrics

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[3] M. Federici, P. V. Federici, F. Feleppa et al., “Pulmonary ultra-sonography in the follow up of respiratory distress syndromeon preterm newborns. Reduction of X-ray exposure,” Journal ofUltrasound, vol. 14, no. 2, pp. 78–83, 2011.

[4] M. Piastra, N. Yousef, R. Brat, P. Manzoni, M. Mokhtari, andD. De Luca, “Lung ultrasound findings in meconium aspirationsyndrome,” Early Human Development, vol. 90, no. 2, pp. S41–S43, 2014.

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[8] R. S. Gereige and P. M. Laufer, “Pneumonia,” Pediatrics inReview, vol. 34, no. 10, pp. 438–456, 2013.

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[10] E. J. Hall, “Lessons we have learned from our children: cancerrisk from diagnostic radiology,” Pediatric Radiology, vol. 32, no.10, pp. 700–706, 2002.

[11] M. A. Pereda, M. A. Chavez, C. C. Hooper-Miele et al., “Lungultrasound for the diagnosis of pneumonia in children: a meta-analysis,” Pediatrics, vol. 135, no. 4, pp. 714–722, 2015.

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[14] V. P. Shah,M.G. Tunik, and J.W. Tsung, “Prospective evaluationof point-of-care ultrasonography for the diagnosis of pneumo-nia in children and young adults,” JAMA Pediatrics, vol. 167, no.2, pp. 119–125, 2013.

[15] J. Liu, S.-W. Chen, F. Liu, Q.-P. Li, X.-Y. Kong, and Z.-C. Feng,“The diagnosis of neonatal pulmonary atelectasis using lungultrasonography,” Chest, vol. 147, no. 4, pp. 1013–1019, 2015.

[16] H. K. Sawires, E. A. Abdel Ghany, N. F. Hussein, and H. M. Seif,“Use of lung ultrasound in detection of complications of respi-ratory distress syndrome,” Ultrasound in Medicine and Biology,vol. 41, no. 9, pp. 2319–2325, 2015.

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